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Biomedical subjects

S Kramer

Publications and source records attributed to S Kramer.

At least 55 records · Page 3Linked to original sources

Identification and its vicissitudes as observed in children: a developmental approach.

In the last thirty-five years, theories derived from observational studies on normally developing infants and toddlers as well as on children with severe pathology have augmented Freud's original contribution to the theory of identification. Mahler's formulations, in particular, are used in this paper to demonstrate the importance for identification of the mutual interaction between mother (or caregiver) and even the very young infant, and to delineate the gradual process by which are achieved intrapsychic self and object-representations. The thread of identification is followed from earliest mirroring of the young infant to post-oedipal ego identifications. I present aspects of the treatment of a borderline adopted boy to demonstrate problems in identification which occurs in part because his two primary caregivers competed to such a degree for possession of him, each demanding loyalty to herself and to herself alone, that his identity and identifications were confused, in fact duplicated. This white child had as his alter-ego, really as part of his self-representation, a black half of the self, personified as a black boy whom he fantasized to be his twin.

Adoption

The need for complex technology in radiation oncology. Correlations of facility characteristics and structure with outcome.

The Patterns of Care Study data are used to correlate therapy equipment and practice characteristics with outcome, using Hodgkin's disease, prostate cancer, and cervix cancer as examples. The shift to linear accelerators and higher photon energy is supported, as is the increased use of treatment simulators. Part-time practitioners of radiation therapy and facilities whose only equipment is a less-than-80-cm cobalt unit have poor technical support and exhibit poor staging, poor achievement of minimum tumor dose, and poor patient follow-up as compared to the national average or best-performing strata of practice. These facilities should either upgrade their equipment, technical support, and level of practice or close.

Delivery of Health Care

Combined preoperative and postoperative radiation for bladder cancer. Results of RTOG/Jefferson Study.

Ninety-two patients with bladder cancer have been treated with combined pre- and postoperative radiation in a Radiation Oncology Study Group (RTOG) Phase I-II study and at Thomas Jefferson University Hospital. Patients with invasive bladder cancer were entered into the study and given low-dose preoperative radiation (500 rad) to the whole pelvis, either on the day of or the day before cystectomy. Following surgery, patients were pathologically staged. Patients with stage B1 (T2) (grade 3 or 4), stage B2 and C (T3) tumors were given 4500 rad in 5 weeks postoperative radiation. Follow-up in the study ranges from a minimum of 24 months to 5 years, with a median of 36 months. Incidence of complications was 15% (14/92). The 4-year actuarial survival (Kaplan-Meier) by stage of disease is 68% for stage B1 (T2) (grade 3 or 4), 78% for stage B2, and 57% for stage C. These survival results appear to be better than those obtained with other approaches of adjuvant therapy and/or surgery in comparable histopathologically staged patients.

Carcinoma, Transitional Cell

Results of adjuvant radiation therapy in cancer of the rectum. Thomas Jefferson University Hospital experience.

From 1972 to 1981, 174 patients with cancer of the rectum surgically staged as B2 or C disease, underwent surgical resection of the tumors for cure. Eighty-eight patients received surgery only with no further adjuvant therapy, and the remaining 86 patients were treated with a combination of radiation and surgery. Twenty-nine patients received low-dose preoperative radiation (500 rad in one fraction); 26 patients received postoperative radiation (4500 rad in 5 weeks); and 31 patients received combined low-dose preoperative radiation (500 rad) and postoperative radiation (4500 rad in 5 weeks). This experience was analyzed to determine the patterns of failure and the impact of adjuvant therapy on survival. Patients undergoing surgery alone had a 26% incidence of local failure in the pelvis and a 57% incidence of distant metastasis. Patients receiving low-dose preoperative radiation had a reduction in the rate of distant metastasis (24%), but no effect on local failure (34%). On the other hand, patients receiving postoperative radiation had a reduction in the local failure rate (11%), with no effect on distant metastasis (50%). Patients who received the combined preoperative and postoperative treatment had a reduction in both the local recurrence rate (7%), and the rate of distant metastasis (13%), and these patients also had a substantial improvement in survival over surgery alone. Survival of patients undergoing surgery alone was 34% at 5 years and was not substantially different for patients undergoing low-dose preoperative irradiation (48%), or for patients receiving postoperative irradiation (29%). Survival in patients receiving combined preoperative and postoperative irradiation was substantially better (78%) than the other groups of patients.

Humans

Is dose/time fractionation important in treating rectal cancer?

In a study to evaluate the effect of increasing dose per fraction on radiation response in rectal cancer, two groups of 29 patients each, matched for extent and size of disease, were evaluated. Group A was treated with conventional dose/fraction (180-200 cGy) X 5 days/week and Group B was treated with 250 cGy/fraction X 4 days/week. Total dose was reduced by 10% in Group B patients to allow comparison of biologically equivalent doses. Two categories of patients were analyzed in each group: patients receiving planned high dose preoperative radiation (4000-4500 cGy); and patients receiving high dose radiation for post-surgical recurrent tumors or locally advanced inoperable tumors (5500-6000 cGy). Tumor regression was markedly better in patients treated with the 250 cGy/fraction. Overall response (greater than 50% regression) was 35% (10/29) in Group A and 62% (18/29) in Group B. Nine of 10 patients in Group B, treated preoperatively, had greater than 50% regression in tumor size, with two patients having no evidence of disease on surgico-pathological evaluation. Six of 10 similar patients in Group A had greater than 50% tumor regression.

Adenocarcinoma

The role of radiation therapy in the management of intracranial meningiomas.

Thirty-two patients with the diagnosis of intracranial meningioma were treated with radiation therapy over the past 24 years at the Thomas Jefferson University Hospital. Indications for irradiation included incomplete resection, malignant histology, and progressive or recurrent disease after curative surgery. Patients with malignant histology did poorly, with only 2 of 7 alive. This contrasts with 17 of 25 patients with benign histology who are either alive and well or who have enjoyed a long-term disease-free survival. No difference in ultimate outcome could be found between patients with benign histology irradiated in the immediate postoperative period as opposed to those irradiated at time of progression or recurrence.

Adolescent

Patterns of care studies: dose-response observations for local control of adenocarcinoma of the prostate.

Five hundred seventy-four patients with prostate cancer treated by external beam radiation therapy in the United States in 1973 to 1975 have been analyzed comparing radiation dose with in-field recurrence. Dose-response effects are observed for all cases (p = less than .05) and T-2 and T-3 tumors, but not for T-0, T-1 and T-4 tumors. For doses calculated at the center of the prostate, these observations suggest optimal control is obtained at no more than 6000 rad for T-0 and T-1 tumors; 6000-6500 rad for T-2 tumors; 6500-7000 rad for T-3 tumors; and that greater than 7000 rad is required only for T-4 tumors. The paraprostatic dose calculated at a point 4 cm lateral to the center of the prostate also shows a correlation of dose with infield failure for all cases (p = .01). Observations in individual T states suggest optimal control is obtained at no more than 6000 rad for T-0, T-1 and T-2 tumors, 6500-6999 rad for T-3 and greater than or equal to 7000 rad for T-4. These data suggest that for T-2 and T-3 cancers, extension in the periprostatic region must be treated. A comparison of central dose vs. stage indicates institutional policy rather than cancer volume determines the radiation dose used in treating prostate cancer. A change in institutional policies to treat with optimal doses as indicated by this study would result in an overall increase in local control and a decrease in complications.

Actuarial Analysis

Carcinoma of the nasopharynx. A 25-year study.

Between 1958-1983, 79 patients with a diagnosis of epithelial tumor of the nasopharynx received definitive irradiation at Thomas Jefferson University Hospital. Seventy-two percent of the patients had a Stage IV lesion. The dose to the nasopharynx was over 6,000 cGy in all but four patients. The 5- and 10-year actuarial survivals were 33% and 19% respectively. The 5-year disease-free survival was 33%. Histology had no bearing on survival. Survival was influenced by the stage of primary tumor and nodes. Advanced nodal disease correlated with distant metastasis, being present in 13/15 cases with hematogenous spread.

Adolescent

Protoporphyrin accumulation by mitogen stimulated lymphocytes and protoporphyrinogen oxidase activity in patients with porphyria variegata and erythropoietic protoporphyria: evidence for deficiency of protoporphyrinogen oxidase and ferrochelatase in both diseases.

In erythropoietic protoporphyria (EPP) and porphyria variegata (PV) excess protoporphyrin is excreted in the stool, suggesting one or more enzyme defects in the terminal steps of the haem biosynthetic pathway. We measured protoporphyrinogen oxidase (PPO), which catalyses the oxidation of protoporphyrinogen to protoporphyrin, in both EPP and PV patients and in the offspring of PV patients. In the same subjects we measured protoporphyrin formation by mitogen stimulated lymphocytes, with delta aminolaevulinic acid (ALA) as substrate and with the addition of chelators or iron, an indirect measure of ferrochelatase activity. PPO activity was reduced by 41% (P less than 0.001) in PV patients and in 50% of their offspring, and by 36% (P less than 0.001) in EPP patients. Protoporphyrin accumulation in stimulated lymphocytes was increased by 1.3-fold (P less than 0.001) in EPP and 1.5-fold (P less than 0.001) in PV patients compared to normal subjects. There was a significant difference in protoporphyrin accumulation between iron deficient and iron replete cells from PV patients as compared to normals but not as marked as for EPP cells treated similarly. Stimulated lymphocytes from prepubertal PV offspring with reduced PPO activity accumulated normal amounts of protoporphyrin. We have interpreted our findings as follows: PPO is significantly reduced in both diseases. Ferrochelatase becomes defective in PV patients after puberty. This could explain why PV is clinically and biochemically manifest only after puberty. As it has been repeatedly shown that ferrochelatase is markedly reduced in EPP, it would appear that both enzymes are deficient in these two porphyrias.

Adult

Radiotherapy of stage I and II Hodgkin disease with inguinal presentation.

Seventeen patients who presented with inguinal adenopathy were found to have stage I or II infradiaphragmatic Hodgkin disease. Sixteen were treated with an inverted-Y field (supplemented by mantle irradiation in 3) and 1 had irradiation of the involved field only. Two patients with stage IIB disease also received MOPP chemotherapy. Fifteen patients currently have no evidence of recurrence; one died of acute myelogenous leukemia 6 years after total nodal irradiation, while another died of cardiopulmonary disease but had no evidence of Hodgkin disease at autopsy. In one patient, progressive peripheral atherosclerosis developed in an irradiated inguinal area, requiring angioplasty. Patient characteristics and results of treatment are analyzed and implications for management presented.

Adolescent

The effect of age on the circadian rhythms of 23 liver or brain enzymes from C57BL/6J mice.

Mice were standardized to 12 h of light exposure alternating with 12 h of darkness and were fed ad libitum. The mice in the first group were 8 weeks old and in the other 104-116 weeks old. Subgroups of 7 animals from each age group were killed at 6 circadian stages. Enzyme activities of 23 enzymes from liver or brain were measured by an analysis of variance for each age group. All but 1 enzyme from young mice, and all but 9 from older mice showed significant changes over time (p less than 0.01). The data from the 22 enzymes from young mice and the 14 enzymes from old mice were fit to the cosinor regression model to further characterize the rhythm. 15 enzymes from the young and 8 from the aged mice showed a significant regression to a 24-hour cosine curve (p less than 0.01); of the 8, 7 were the same enzymes in both groups. Amplitude changes, where they could be compared from the cosinor data (7 enzymes), were not statistically different. When total variance was compared, 12 enzymes showed unequal variance. Of these, old mice had the larger variance in 9 enzymes. Another difference between the young and the old was changes in mean enzyme activities. 12 enzymes from aged mice had decreased mesors, 2 had increased mesors, and 9 were unchanged. In general, our data suggest that some enzyme activity rhythms were lost, others were altered and a few were not affected by aging. In the case of many enzymes, older mice have a diminished ability to synchronize to the light signals.

Animals

Women in prison.

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Female

Racial variation in incidence of Wilms' tumor: relationship to congenital anomalies.

This is a study of the occurrence of Wilms' tumor and associated anomalies in all incident cases in the Greater Delaware Valley by race. The average annual incidence of Wilms' tumor in this population of 2 million children is significantly higher among nonwhites than whites. A significantly larger proportion of black cases has a Wilms' tumor-associated condition including aniridia, genito-urinary anomalies, the Beckwith-Wiedemann Syndrome, and hemihypertrophy. For very young patients, there was a greater tendency for blacks to have bilateral tumors or a tumor-associated anomaly, features characteristic of the hereditary form of Wilms' tumor. The excess risk of Wilms' tumor among blacks may be a result of a higher proportion having a hereditary predisposition or more common exposure to agents capable of inducing germinal mutations.

Abnormalities, Multiple

An on-line interactive interviewing program for epidemiological studies.

An on-line interactive verification and entry system (OLIVES) has been developed for conducting telephone interviews in large-scale epidemiological studies. Responses are automatically coded into a computer legible form suitable for analysis. Use of a question stack to control question flow allows on-line response modification, restart from any termination point, and minimal reprogramming in order to change question order. Numerical, coded, and text string data types are permitted. A multilevel hierarchical data structure reflects interview content. The advantages and disadvantages of the on-line approach are discussed. OLIVES is generalizable and is applicable to other on-line or off-line interview situations.

Child

In vitro reconstitution of nitrate reductase activity of the Neurospora crassa mutant nit-1: specific incorporation of molybdopterin.

The reduced, metal-free pterin of the molybdenum cofactor has been termed molybdopterin. Oxidation of any molybdopterin-containing protein in the presence or absence of iodine yields oxidized molybdopterin derivatives termed Form A and Form B, respectively. Application of these procedures to whole cells and cell extracts has demonstrated the presence of molybdopterin in wild-type Neurospora crassa, and its absence in the cofactor-deficient mutant nit-1. In order to demonstrate that the reconstitution of nitrate reductase activity in nit-1 extracts results from the incorporation of molybdopterin into the apoprotein, active molybdopterin, free of contaminating amino acids or peptides, was isolated from chicken liver sulfite oxidase and used in the reconstitution system. The results show that, during reconstitution, exogenous molybdopterin is specifically incorporated into the nitrate reductase protein, confirming the role of molybdopterin as the organic moiety of the molybdenum cofactor.

Amino Acids

Patterns of care outcome studies: results of the national practice in adenocarcinoma of the prostate.

The Patterns of Care Study reviewed the processes and outcome of 682 patients with carcinoma of the prostate treated with radiation therapy from 1973-1976. The study and patient sampling were designed to reflect a valid representation of how prostate cancer is treated by radiation oncologists in the United States. The outcome results represent national benchmarks. The three year actuarial survival was 91% for Stage A, 88% for Stage B, and 76% for Stage C. The three year relapse free survival rate was 85% for Stage A, 77% for Stage B, and 59% for Stage C. The infield recurrence rates were: Stage A--4%, Stage B--9%, and Stage C--20%. Stage, grade, elevated serum acid phosphatase, Karnofsky performance status, previous hormonal therapy, age, and prior transurethral resection were identified by multivariate regression analysis to be important independent prognostic variables. Local control was related to the dose of the primary site, paraprostatic region, and pelvic sidewall. Local control was significantly improved if the facility's best treatment equipment was a linear accelerator. Major complications occurred in 9% of patients with Stage A, 2% of Stage B, and 6% with Stage C disease. Complications were related to dose and treatment technique. The Patterns of Care Process Survey identified that only 60% of patients surveyed had the necessary pretreatment evaluation studies required for best current management of adenocarcinoma of the prostate. Variance occurred within each stratum of facilities sampled. Strict attention to the details of evaluation of therapy will help to enhance the delivery of optimal radiation therapy in the management of patients with carcinoma of the prostate.

Adenocarcinoma

Adjuvant radiation therapy for rectal cancer.

Since 1976, 104 patients with rectal cancer have been treated with a new approach of combined pre- and postoperative radiation. All patients were given 500 rad preoperative irradiation on the day of or the day before surgery. Surgery in the majority of patients was an abdominal perineal resection. The disease was then staged pathologically according to Astler-Coller's modification of Duke's staging. Patients with early stage cancer (Stages A and B1) were followed with no further therapy. Patients with poor prognostic characteristics (Stages B2, C1, C2) were given postoperative pelvic irradiation (4500 rad in 5 weeks). Twenty-nine patients were found to have Stage A or B1 cancer and were followed with no further therapy. Of these 29 patients, 1 patient developed recurrence and one has died of metastatic disease. The excellent survival of patients with early tumors indicates that minimizing the role of adjuvant therapy in this group has not been detrimental to their survival. Fifteen were found to have liver metastases at laparotomy and had just a colostomy and palliative therapy. Sixty patients had Stage B2 and C disease. Thirty-one received postoperative irradiation as per protocol. Twenty-nine patients did not receive postoperative irradiation for a variety of reasons. Follow-up ranges from 1 to 7 years in these patients. Of the 29 patients with Stage B2 and C disease who should have but did not receive postoperative radiation, 10 patients (34%) have developed a recurrence in the pelvis, and 5 other patients (17%) have developed metastatic disease. Of 31 patients who received postoperative irradiation, only 2 patients (6%) developed a local recurrence and 4 patients (13%) have developed distant metastases. Survival at 3 years was 80% for patients receiving the combined treatment, as compared to 42% for those not receiving the postoperative part of the treatment protocol.

Adenocarcinoma